Head & Brain Trauma

EMS Professions Temple College

Head & Brain Trauma 

~ 4 million head injuries in US per year ~ 450, 000 require hospitalization 

Most are minor injuries Major head injury most common cause of trauma deaths in trauma centers (>50%)

Head & Brain Trauma 

Risk Groups 

Highest: Males 15-24 yrs of age Very young children: 6 mos to 2 yrs of age Young school age children Elderly

mastoid Middle meningeal artery lies under temporal bone  common source of epidural hematoma   Foramen magnum Facial Bones discussed later  . parietal.Skull Anatomy Review  Cranium    Double layer of solid bone which surrounds a spongy middle layer Frontal. temporal. occipital.

Brain Anatomy Review   Occupies 80% of intracranial space Divisions    Cerebrum Cerebellum Brain Stem .

Brain Anatomy Review  Cerebrum  Cortex ± Voluntary skeletal movement ± level of awareness  Frontal lobe ± Personality  Parietal lobe ± somatic sensory input ± memory ± emotions .

Brain Anatomy Review  Cerebrum  Temporal lobe ± ± ± ± speech center long term memory taste smell  Occipital lobe ± origin of optic nerve .

regulation of body temp and water ± sleep-cycle control ± appetite  Thalamus ± emotions and alerting or arousal mechanisms  Cerebellum   coordination of voluntary muscle movement equilibrium and posture .Brain Anatomy Review  Cerebrum  Hypothalamus ± center for vomiting.

cerebellum and SC responsible for vegetative functions & VS midbrain ± relay point for visual and auditory impulses  pons ± conduction pathway between brain and other regions of body  medulla oblongata ± cardiac. and vasomotor control centers ± control of vomiting and coughing .Brain Anatomy Review  Brain Stem    connects hemispheres. respiratory.

venous vessels that reabsorb CSF ± pia mater: directly attached to brain tissue . landmark for lesions ± arachnoid: web-like.Brain Anatomy Review  Brain Stem   Cranial Nerves Reticular Activating System ± level of arousal (level of consciousness)  Primary control along with cerebral cortex  Meninges ± dura mater: tough outer layer. separates cerebellum from cerebral structures.

colorless circulates through brain and spinal cord cushions and protects ventricles  center of brain  secrete CSF by filtering blood  forms blood-brain barrier .Brain Anatomy Review  Brain Stem  Cerebral Spinal Fluid (CSF) ± ± ± ± clear.

Brain Metabolism & Perfusion  High metabolic rate     consumes 20% of body¶s oxygen largest user of glucose requires thiamine can not store nutrients vertebral arteries ± supply posterior brain (cerebellum and brain stem)  Blood Supply   carotid arteries ± most of cerebrum .

Intracranial Pressure (ICP) .Brain Metabolism & Perfusion  Perfusion  Cerebral Blood Flow (CBF) ± dependent upon CPP ± flow requires pressure gradient  Cerebral Perfusion Pressure (CPP) ± pressure moving the blood through the cranium ± autoregulation allows BP change to maintain CPP ± CPP = Mean Arterial Pressure (MAP) .

hemorrhage ± ICP usually 10-15 mm Hg .Brain Metabolism & Perfusion  Perfusion  Mean Arterial Pressure (MAP) ± largely dependent on cerebral vascular resistance (CVR) since diastolic is main component ± blood volume and myocardial contractility ± MAP = Diastolic + 1/3 Pulse Pressure ± usually require MAP of at least 60 mm Hg to perfuse brain  Intracranial Pressure (ICP) ± edema.

Mechanisms of Injury  Motor Vehicle Crashes   most common cause of head trauma most common cause of subdural hematoma   Sports Injuries Falls   common in elderly and in presence of alcohol associated with subdural hematomas missiles more common than sharp projectiles  Penetrating Trauma  .

tearing or stretching of nerve fibers more common with vehicle occupant and pedestrian limited and identifiable site of injury  Contrecoup injury    Diffuse Axonal Injury (DAI)    Focal Injury  .Categories of Injury  Coup injury   directly posterior to point of impact more common when front of head struck directly opposite the point of impact more common when back of head struck shearing.

bony structures. focal brain injury. DAI  Penetrating Trauma ± less common (GSW most common) ± dura and cranial contents penetrated ± fractures. focal brain injury . and/or brain injury Blunt Trauma ± more common ± dura intact ± fractures.Head Injury  Broad and Inclusive Term   Traumatic insult to the head that may result in injury to soft tissue.

emotional.Brain Injury   ³a traumatic insult to the brain capable of producing physical. social and vocational changes´ Three broad categories  Focal injury ± cerebral contusion ± intracranial hemorrhage ± epidural hemorrhage   Subarachnoid hemorrhage Diffuse Axonal Injury ± concussion (mild and classic form) . intellectual.

tissue hypoxia. hypotension. ECG changes . pulmonary resistance. pressure  Indirect (Secondary or Tertiary) Causes   Tertiary ± apnea. infection. inadequate perfusion. hemorrhage.Causes of Brain Injury  Direct (Primary) Causes    Impact Mechanical disruption of cells Vascular permeability or disruption Secondary ± edema.

cerebral vasodilation occurs to blood volume  This leads to further ICP. CPP and so on .Pathophysiology of Brain Injury  As ICP flow   and approaches MAP. cerebral blood  Results in CPP Compensatory mechanisms attempt to MAP As CPP .

cerebral vasodilation occurs to blood volume And.Pathophysiology of Brain Injury  Hypercarbia causes cerebral vasodilation     Results in blood volume ICP CPP Compensatory mechanisms attempt to MAP As CPP . the cycle continues  Hypotension results in vasodilation   CPP ICP cerebral CPP Results in blood volume And. the cycle continues .

Pathophysiology of Brain Injury  Pressure exerted downward on Brain  cerebral cortex or RAS ± altered level of consciousness  hypothalamus ± vomiting  brain stem ± BP and bradycardia 2° vagal stimulation ± irregular respirations or tachypnea ± unequal/unreactive pupils 2° oculomotor nerve paralysis ± posturing   seizures dependent on location of injury Herniation .

Pathophysiology of Brain Injury  Levels of Increasing ICP  Cerebral cortex and upper brain stem ± ± ± ± BP rising and pulse rate slowing Pupils reactive Cheyne-Stokes respirations Initially try to localize and remove painful stimuli Wide pulse pressure and bradycardia Pupils nonreactive or sluggish Central neurogenic hyperventilation Extension  Middle brain stem ± ± ± ± .

Pathophysiology of Brain Injury  Levels of Increasing ICP  Lower Brain Stem / Medulla ± ± ± ± ± ± Pupil blown (side of injury) Ataxic or absent respirations Flaccid Irregular or changing pulse rate Decreased BP Usually not survivable .

Pathophysiology of Brain Injury  Herniation  transtentorial herniation ± downward displacement of the brain  uncal herniation ± ³downward displacement through the tentorial notch by a supratentorial mass exerting pressure on underlying structures including the brain stem´ .

Head Injuries  Scalp Laceration/Avulsion     Most common injury Vascularity = diffuse bleeding Generally does not cause hypovolemia in adults Can produce hypovolemia in children .

Head Injuries Depressed Linear Stellate Basilar Skull Fractures .

Head Injuries  Linear Fracture  Usually NOT identified in field ± 80% of all skull fractures  Suspect based on ± Mechanism of injury ± Overlying soft tissue trauma   Usually NOT emergency Temporal region = ~Epidural hematoma .

Head Injuries  Depressed Skull Fracture   Segment pushed inward Pressure on brain causes brain injury ± Neurologic signs and symptoms evident .

Head Injuries  Basilar Skull Fracture    Difficult to detect on x-ray Signs & Symptoms depend on amount of damage Diagnosis made clinically by finding: ± CSF Otorrhea ± CSF Rhinorrhea ± Periorbital ecchymosis ± Battle¶s sign .

Head Injuries  Cerebrospinal Fluid     Blood clotting delayed Halo sign Does not crust on drying Positive to Dextrostick .

Head Injuries  Basilar Skull Fracture     Do NOT pack ears Let drain Do NOT suction fluid Do NOT instrument nose .

clean dressing (if possible) Neurologic signs & Symptoms evident .Head Injuries  Open Skull Fracture     Cranial contents exposed Manage like evisceration Protect exposed tissue with moist.

Brain Injuries  Intracranial Hematomas    Epidural Subdural Intracerebral .

Brain Injuries  Epidural Hematoma   Blood between skull and dura Usually arterial tear ± middle meningeal artery  Causes increase in intracranial pressure .

headache. decreased pulse (Cushing¶s reflex) . hemiplegia Unequal pupils (dilated on side of clot) Increase BP. vomiting Hemiparesis. nausea.Brain Injuries  Epidural Hematoma       Unconsciousness followed by lucid interval Rapid deterioration Decreased LOC.

Brain Injuries  Subdural Hematoma    Between dura mater and arachnoid More common Usually venous ± bridging veins between cortex and dura  Causes increased intracranial pressure .

Brain Injuries  Subdural Hematoma      Slower onset Increased ICP Headache. unequal pupils Increased BP. hemiplegia . decreased LOC. decreased pulse Hemiparesis.

Brain Injuries  Intracerebral Hematoma    Usually due to laceration of brain Bleeding into cerebral substance Associated with other injuries ± DAI  Neuro deficits depend on region involved and size ± repetitive w/frontal lobe  Increased ICP .

Brain Injuries  Injury to Cerebral Parenchyma    Laceration Concussion Contusion .

Brain Injuries 


Penetrating wounds
±GSW ±Stab ±Depressed Fracture  

Severe blunt trauma Sudden acceleration/deceleration

Brain Injuries 


Transient loss of consciousness Retrograde amnesia, confusion Resolves spontaneously without deficit Usually due to blunt head trauma

Head Trauma 


Post-concussion syndrome
±Headaches ±Depression ±Personality changes

Head Trauma Assessment The Brain Is Enclosed In A Box .

Head Trauma Assessment Early Detection/Control of Increased ICP Critical .

Intracranial Pressure CPP = MAP .ICP .Head Trauma Assessment Cerebral Perfusion Pressure = Mean Arterial Pressure .

Head Trauma Assessment  LOC = Best Indicator   Altered LOC = Intracranial trauma UPO Trauma patient unable to follow commands = 25% chance of intracranial injury needing surgery .

Head Trauma Assessment Describe LOC changes based on response to environment .

Head Trauma Assessment  AVPU Scale A = Alert V = Responds to Verbal stimuli P = Responds to Painful stimuli U = Unresponsive     .

Head Trauma Assessment  Glasgow Scale    Eye Opening Motor Response Verbal Response .

Head Trauma Assessment  Glasgow Scale--Eye Opening     4 = Spontaneous 3 = To voice 2 = To pain 1 = Absent .

Incomprehensible 1 = No response .Head Trauma Assessment  Glasgow Scale--Verbal      5 = Oriented 4 = Confused 3 = Inappropriate words 2 = Moaning.

Head Trauma Assessment  Glasgow Scale--Motor       6 = Obeys commands 5 = Localizes pain 4 = Withdraws from pain 3 = Decorticate (Flexion) 2 = Decerebrate (Extension) 1 = Flaccid .

equality. and response to light .Head Trauma Assessment  Eyes   Window to CNS Pupil size.

Head Trauma Assessment  Eyes  Unequal Pupils + Decreased LOC = ±Compression of oculomotor nerve ±Probable mass lesion  Unequal Pupils + Alert patient = ±Direct blow to eye. or ±Oculomotor nerve injury. or ±Normal inequality .

Head Trauma Assessment  Respiratory Patterns  Cheyne Stokes ±Diffuse injury to cerebral hemispheres  Central neurological hyperventilation ±Injury to mid-brain  Apneustic ±Injury to pons .

Head Trauma Assessment  Respiratory Patterns  Biot (Cluster) ±Injury to upper medulla  Ataxic ±Injury to lower medulla .

Head Trauma Assessment  Motor Response   Is patient able to move all extremities? How do they move? ±Decorticate ±Decerebrate ±Hemiparesis or Hemiplegia ±Paraplegia or Quadraplegia .

Head Trauma Assessment  Motor Response   Lateralized/Focal Signs = Lateralized or Focal Deficits Altered motor function may be due to fracture/dislocation .

Head Trauma Assessment  Vital Signs   Cushing¶s Triad Suggests Increased Intracranial Pressure ±Increased BP ±Decreased Pulse ±Irregular respiratory pattern .

Head Trauma Assessment  Vital Signs   Isolated head injury will NOT cause hypotension in adult Look for another life threatening injury ±Chest ±Abdomen ±Pelvis ±Multiple long bone fractures .

Head Trauma Assessment  Summary     Most important sign = LOC Direction of changes more important than single observations Importance lies in continued reassessment compared with initial exam UPO. altered LOC in trauma = Intracranial injury .

Suction As Needed Maintain ±Intubation if No Gag Reflex.Head Trauma Management  Airway    Open ±Assume C-spine Trauma ±Jaw Thrust with C-spine Control Clear . or ±RSI ±Avoid nasal intubation .

Head Trauma Management  Breathing     Oxygenate .100% O2 Ventilate No ROUTINE Hyperventilation Hyperventilate at 20 to 24 breaths per minute IF: ±Glasgow less than 8 ±Rapid neurologic deterioration ±Evidence of herniation .

Head Trauma Management  Hyperventilation--Benefits ±Decreased PaCO2 ±Vasoconstriction ±Decreased ICP .

Head Trauma Management  Hyperventilation--Risks ±Decreased cerebral blood flow ±Decreased oxygen delivery to tissues ±Increased edema .

Head Trauma Management  Circulation     Maintain adequate BP and Perfusion IV of LR/NS TKO if BP normal or elevated If BP decreased ±LR/NS bolus titrated to BP ~ 90 mm Hg ±Consider PASG/MAST if BP below 80 Monitor EKG -.Do NOT treat bradycardia .

Head Trauma Management   Spinal motion restriction If BP normal or elevated. spine board head elevated 300 .

Head Trauma Management  Monitor for hyperthermia Vasoconstriction Heat retention Increased cerebral 02 demand    .

Head Trauma Management   Drug Therapy Considerations Only after: Management of ABC¶s Controlled hyperventilation   .

Head Trauma Management  Drug Therapy Considerations Dexamethasone (Decadron®)  ±Steroid ±Decreases cerebral edema ±Effects delayed ±Little usage today .

Head Trauma Management  Drug Therapy Considerations  Mannitol (Osmitrol®) ±Osmotic diuretic ±Decreases cerebral edema ±May cause hypovolemia ±May worsen intracranial hemorrhage ±Often reserved for herniation .

Head Trauma Management  Drug Therapy Considerations Furosemide (Lasix®)  ±Loop diuretic ±Decreases cerebral edema ±May cause hypovolemia ±Often reserved for herniation .

Head Trauma Management  Drug Therapy Considerations Diazepam (Valium®)  ±Anticonvulsant ±Give if patient experiences seizures ±May mask changes in LOC ±May depress respirations ±May worsen hypotension .

Head Trauma Management  Drug Therapy Considerations Glucose  ±Assess blood glucose ±Administer only if hypoglycemic ±Consider thiamine in malnourished .

Head Trauma Management  Transport Considerations  Trauma Center ±GCS < 12 Evidence of herniation  Unconscious  Multisystem trauma with head trauma  Consider comorbid factors  .

Head Trauma Management  Helmet Removal  Immediate removal if interferes with priorities ± access to airway or airway management ± ventilation ± cervical spine motion restriction    May only need to remove face piece to access airway Consider interference with SMR Technique ± requires adequate assistance ± training in the procedure ± padding if shoulder pads left on .

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